Continuous Improvement and Quality Management Policy
| Policy area | Service Delivery |
| Document type | Policy |
| Applicable to | Beyondlimits Care & Support Services |
| Version | 001 |
| Date approved | 19/08/2024 |
| Approved by | Managing Director |
| Next review date | Every 12 Months |
| Related policies | Incident Management Policy Risk Management Policy Client Feedback and Complaints Management Policy Client Health and Wellbeing Policy Client Living Alone and Receiving Personal Care from Sole Worker Policy Safeguarding Against Violence, Abuse, Neglect, Exploitation and Discrimination Policy Duty of Care Policy Client Advocacy Policy Consent Policy Diversity Policy Support Planning Policy Service Access and Exit Policy Service Delivery Policy Privacy Policy Work Health and Safety Policy Waste Management Policy Human Resources Management Policy Information Management Policy Governance Policy |
| Authority | NDIS Act 2013 NDIS Practice Standards and Quality Indicators NDIS Code of Conduct Aged Care Act 1997 Aged Care Quality and Safety Standards Aged Care Code of Conduct Privacy Act 1988 |
PURPOSE
The purpose of this policy is to explain our organisation's commitment and approach to continuous improvement and quality management.
SCOPE
This policy applies to all our workers (employees, contractors and volunteers).
DEFINITIONS
| Term | Definition |
|---|---|
| Complaint | An expression of dissatisfaction with a support or service where standards or expectations have not been met. |
| Continuous Improvement | A deliberate and sustained effort to improve processes and adopt a 'learning' culture. It involves cyclical steps: identifying opportunities for improvement; collecting and analysing data; deciding on new approaches based on data analysis; developing and implementing changes and evaluating the effectiveness of the changes. |
| Deming Cycle | A management methodology incorporating integrated knowledge and learning, with the aim of continually improving processes. This cycle is based on four stages: Plan; Do; Check; and Act. |
| Open Disclosure | A management methodology incorporating integrated knowledge and learning, with the aim of continually improving processes. This cycle is based on four stages: Plan; Do; Check; and Act. |
| Internal Audit | Independent, objective assurance and consulting activity designed to add value and improve operations. It adopts a systematic and disciplined approach to evaluating and improving the effectiveness of a quality management system. |
| Corrective Action | An action, or a plan created to address a non-conformance from an internal or external audit. |
| Performance Indicators | Measures that evaluate outcomes or results. |
CONTEXT
Our organisation is committed to maintaining safety and quality and continually improving our service delivery and business operations. We will adopt a ‘Plan; Do; Check; and Act’ approach to continuous improvement and quality management which:
- is proportionate to the size and scale of our organisation and the scope and complexity of supports provided;
- prioritises client health, safety and wellbeing;
- promotes a learning culture where gaps, opportunities, input and feedback (including complaints) from stakeholders are encouraged and welcomed;
- integrates planning, resource allocation, risk management and reporting as part of the continuous improvement process;
- provides cultural and language-accessible modes and methods for clients to submit feedback and complaints;
- fosters a resolution-based culture of open disclosure;
- upholds clients’ human rights — including their right to privacy, confidentiality, dignity and respect;
- promotes clients’ right to choice, control and self-determination;
- encourages and supports client independence and capacity-building, where possible; and
- implements changes as required and evaluates the effectiveness of those changes.
POLICY STATEMENT
#1
Implementing and Maintaining a Quality System
- We will implement and maintain a quality system that:
- is integrated in our overall risk management and compliance framework;
- clearly defines role accountabilities and responsibilities for ensuring safety and quality in service delivery;
- supports the timely and accurate collection of data so we can identify, analyse, monitor and report risks, complaints and incidents; and
- provides trend analysis functionality so we can identify process gaps and continually improve our service delivery.
#2
Identifying Opportunities for Improvement
- We will strive to continually improve our processes to provide clients with safe and quality services and support.
- We will maintain processes that are consistent with our mission, vision and values.
- We will continually review and evaluate our processes and make changes as required.
#3
Encouraging and Acknowledging Feedback and Complaints
- We will ensure clients are aware of their right to provide feedback and make a complaint, both internally and externally, and support them to do this if requested.
- We will actively engage with clients and their family/alternate decisionmaker/advocate, workers and other stakeholders and use their input and feedback for continuous improvement and quality management.
- We will acknowledge a complaint, demonstrating courtesy and respect, verbally and/or in writing to a complainant and express verbal gratitude to acknowledge a compliment.
#4
Collection, Collation and Evaluation of Information and Data
- We will maintain processes to collect, collate and evaluate information and data to identify gaps, systemic issues, errors, opportunities for improvement and nonconformances
- We will maintain a Continuous Improvement Register, Complaints Register, Incident Register and Risk Register with details, actions and outcomes of complaints, incidents, risks and suggested/required improvements
#5
Reviewing and Monitoring Processes
- We will review board and management processes to ensure roles and responsibilities align with mission, vision and strategy.
- We will conduct internal audits to review and monitor processes and operations and make any required adjustments.
- We will participate in external audits and view them as an opportunity to learn and continually improve.
- We will review feedback, suggestions, complaints and incidents to identify systemic issues and take follow up action(s) as required (changes to policy and procedures, worker rostering, supervision and training, technology and communications).
- We will review and revise our policies, procedures, forms and templates to ensure currency, accuracy and compliance.
#6
Information and Record-keeping
- We will ensure information and records are accurate and up to date.
- We will ensure the client has provided us with all required written consents.
- We will store the information securely to ensure privacy, dignity and confidentiality and make sure it is accessible to the client and only other stakeholders authorised to access it.
#7
Worker Training and Supervision
- We will maintain a skilled and trained workforce, which supports our mission, vision and values and recognises the importance of continuous improvement.
- We will maintain processes to adequately monitor and supervise workers.
SUPPORTING DOCUMENTS
Related procedures and forms include:
- Continuous Improvement and Quality Management Procedure
- Reportable Incident Management Procedure
- Incident Management Procedure
- Support Planning Procedure
- Service Access and Exit Procedure
- Service Delivery Procedure
- Client Advocacy Procedure
- Client Feedback and Complaints Management Procedure
- Safeguarding Against Violence, Abuse, Neglect, Exploitation and Discrimination Procedure
- Managing Data Breach Procedure
- Complaint and Feedback Form
- Anonymous Complaint and Feedback Form
- Complaints Process Checklist
- Complaint Register
- Continuous Improvement Plan Register
- Service Agreement
- Incident Investigation Form — Final Report
- Incident Report
- Incident Register
- Hazard Report Form
- Internal Audit Schedule
- Risk Assessment Form
- Risk Management Plan Register
RESPONSIBILITIES
Managing Director is responsible for:
- maintaining this policy, its related procedures and associated documents;
- ensuring the policy is effectively implemented across the service;
- monitoring workers compliance with the requirements of this policy; and
- ensuring training and information is provided to workers to carry out this policy.
All workers are responsible for complying with the requirements of this policy.
COMPLIANCE
Deliberate breaches of this policy will be dealt with under our misconduct provisions, as stated in the Code of Conduct Agreement.
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